Abstract
It is important to carefully select patients for botulinum toxin rejuvenation treatment. It must be clear to the patient what the injection will do and how it works. The patient must also be fit to comprehend his or her choices. Some patients misunderstand that botulinum toxin can lift a muscle directly, as opposed to paralysing it. Other patients confuse botulinum toxin with fillers. Realistic expectations must be set, depending on the condition of the patient’s skin and the age of the patients. Short-term management is ideal for occasions, whilst other patient prefer to use botulinum toxin long term to ‘train’ their reflex expressions, for example, to reduce frowning through neuromodulation and reduction of central neuronal signalling. A thorough examination of the patient will reveal likely unwanted results prior to treatment. Low brows and heavy dermatochalasis will require upper blepharoplasty to reduce frontalis elevation of brows. Ptosis must also be corrected prior to treating the forehead muscles.
Keywords
Young, older patient, neuromodulation, reflex expression, dermatochalasis, brow lift, depression, comprehension.
Some patients have a clear idea of their requirements and a good aesthetic sense. Others trust their doctors to advise them on ‘what looks good’. They may come for treatment only because they were told to do so by their friends or their parents. If so, they may resent a treatment to which they are not fully committed.
The golden rule here is that if patients are not going to derive any perceivable pleasure from botulinum toxin, then their expenditure will not be properly rewarded. Their trust in their physician will be reduced, almost as if they had been ‘sold’ a dress in a shop that they did not really want—such shops are rarely revisited. It is important not to be influenced by such patients’ demands. If the wrong decision is made by the physician and treatment is refused, then at least no harm is done. The botulinum treatment cannot be ‘undone’ 1 week later if the patient is unhappy with the outcome (even though the physician had already described the implications of treatment clearly). Above all, remember that no one NEEDS botulinum toxin for rejuvenation.
Patients frequently misunderstand the role of botulinum toxin and make an appointment to have it because they heard it advertised and want to ‘lift’ their face. It is a good idea to politely educate the patient as to how botulinum toxin actually works, and once they understand its effect on a muscle, inform them too about how wrinkles form.
How to identify suitable patients
Listen to their presenting complaint and then, while still looking at the patient, decide quickly whether it can be treated with botulinum toxin or not.
Continue the consultation while carefully assessing the patient’s psychological suitability (more later).
If, on first impression, the patient seems suitable, spend time providing verbal and written information about the treatment (this can be done by a trained nurse).
Always examine patients closely—as described in the following chapters—and discuss the likely outcome of botulinum toxin injections with them.
Be sure that your patients understand what has been said fully before they sign the consent form.
Selection process
The decision must be made, prior to treatment, as to whether botulinum toxin can eliminate rhytids, reduce them and prevent further rhytids or whether another type of treatment is necessary. Consider whether patients are likely to look unusual after treatment (e.g. with peaked brows or tired appearance with heavy brows). Would they be better to avoid treatment altogether, to have gradual treatment over a few weeks or to have a different treatment?
The patient should have given an accurate age and history of smoking ( Table 6.1 ) (although some do not!), and a full medical history reveals no obvious contraindications such as myasthenia gravis, pregnancy, etc. (see Chapter 7 ).
| Consider the following: | Look for: |
|---|---|
| General skin condition | Sun damage, pigment spots, poor tone. |
| Age | Cardiovascular status, skin perfusion, overall tone and skeletal structure. |
| Brow position | Examine lash/brow distance. |
| How does it change with expression? | |
| Are the forehead wrinkles the result of ‘holding’ brows? | |
| Crow’s feet | At rest or in motion? |
| Do they extend down towards the perioral lines when smiling? | |
| Hooding | Is there a fold of skin at the corner of the eye that disappears when the patient lifts the brow? |
All new patients must be assessed physically and mentally. Written information about botulinum toxin should be provided at the time of consultation, and patients should have time to digest this before an opportunity is provided to ask the physician any relevant questions.
Initial physical assessment: Age and skin condition
With experience, it is possible to decide at a glance whether or not botulinum toxin will help a patient and what changes to the face may be expected as a result of the treatment (see Chapter 5 on neuromodulation). For example, a 29-year-old nonsmoker with crow’s feet that wrinkle only when she is smiling will do very well ( Fig. 6.1 ). Botulinum toxin will rid her of wrinkles completely. On the other hand, her sporty friend of the same age, who had not used adequate sun protection, may have wrinkles at rest with an early reduction in lower lid skin tone. Time must be spent explaining to her that she may possibly be disappointed with botulinum toxin—the injections might help to stop the clock and avoid new rhytids, but without alternative treatments (including sun protection, laser resurfacing, stopping smoking) she will continue to have her wrinkles.
Expected botulinum toxin treatment outcomes may be addressed for short- and long-term management groups. Some patients just want a treatment for a special occasion; many patients resist the idea of long-term repeated injections. Other patients want a long-term maintenance plan in keeping with their personal health and self-care agendas.
Short term management
Short-term treatment can be ideal for a special occasion and for many patients is their only affordable option. One treatment can quickly eliminate dynamic lines and soften the underlying static lines, but the effect almost always lasts only 12 weeks, particularly if the treated muscle is very strong. Suitability depends on age.
Crow’s feet always return! It appears that the innate drive to smile, particularly as a muscle paired with perioral smile muscles for expression, is deeply embedded in our primal drive.
Patients may be reassured with photographs that regular botulinum toxin injections are not necessary to eliminate static rhytids and that these may be eliminated with CO 2 laser at any time.
Short-term botulinum toxin (e.g. one treatment lasting 12 weeks) is often indicated following CO 2 resurfacing to maintain a flat muscle as the skin recovers and builds up its collagen ( Fig 6.2 A and B, crow’s feet pre- and post-CO 2 laser resurfacing).
Younger patients (<35 years old) do very well with ‘one off’ treatments. They respond quickly, and their underlying skin tone usually protects them from untoward thinning or sagging ( Fig. 6.3 A and B). They can usually receive stronger concentrations of botulinum toxin to the full body of their muscles with maximum duration of effect.
